Rational and objectives
Nikhil Dubey BDS Intern,GDC Raipur
Non surgical
*Why do we do periodontal surgery?
*To provide access and direct vision of the
root surfaces for thorough debridement.
Because in some situation non –surgical
therapy is not enough to clean the
Surgical periodontal therapy
seeks to
Improve the prognosis of teeth.
Improve aesthetics.
Purpose of surgical pocket
To eliminate the pathological changes in
the pocket walls.
To create a stable, easy maintainable
May promote periodontal regeneration .
To gain surgical access to deep pockets
for adequate cleaning and smoothening of
the root surfaces.
 To facilitate plaque control by reduction or
elimination of potential plaque retention
areas(correction of morphologic defects).
Objectives, cont.
To provide an environment for an
adequate prosthesis.
For periodontal regenerative therapy.
To correct cosmetic abnormalities.
Indications for periodontal
Areas with irregular bony contours or deep
Pockets on teeth in which a complete removal of
root irritants is not considered clinically possible.
In cases of grade II or III furcation involvement.
Infrabony pockets in distal areas of last molars.
Persistent inflammation in areas with moderate
to deep pockets may require a surgical
Patients who do not exhibit good plaque control.
 Uncontrolled or progressive systemic disease
(uncontrolled diabetics,leukemia ect.).
 Patients taking large doses of corticosteriods
may have reduced resistance to stress
associated with surgery ..
 Patients with imminent terminal disease who are
debilitated are not candidates for surgery.
Results of pocket therapy
Conversion of an active pocket to inactive
pockets and heal by long junctional
epithelium with or without gain of
 Pocket elimination or reduction.
 Improved gingival attachment promotes
restoration of bone height, with
reformation of periodontal ligament fibers
and layers of cementum.
Surgical instruments
Classification of periodontal
Introductory points:
Pocket is a pathological deepening of the
 Initially ------Pocket (8mm)
 Re-evaluation------Pocket(6mm)
 We need to gain access for thorough
 However, some time we add bone and
some time we resects bone.
Classification of periodontal
New attachment
Resective procedures
 It
is the procedure that means to
eliminate or reduce the pocket, by
excising or amputating the tissue
constricting the pocket wall.
 (in this case we remove bone).
New attachment procedures
 It
is the reunion of connective tissue
by formation of new cementum with
inserting collagen fibers on root
surface that has been deprived of its
periodontal ligament.
Regeneration procedures
Are surgical procedures aimed at
Reproduction or reconstruction of lost or
injured periodontium.
 Aim is to restore the periodontium to the
normal physiologic levels. We have new
bone and periodontal ligament formation
Resective procedures includes:
Gingivectomy, Gingivoplasty.
 Apically positioned flap without osseous
 Apically positioned flap with osseous
surgery (Osteoplasty, Osteoctomy).
 Root resection.
Gingivectomy:Excision of soft tissue wall
of periodontal pocket.
 Basic rational is pocket elimination to
allow access for root instrumentation.
 Gingivoplasty:To restore gingival
contours.(not commonly used now days).
 External bevel incision is done to remove
excess gingiva and healing is by secondary
Apically positioned flap without
osseous surgery
The idea is to move the gingival margin
Apically and not to excise the gingiva.
 Indications:
 Deep supra and infra bony pockets.
 Crown lengthening procedures with
minimal attached gingiva.
 Increase the zone of attached gingiva.
Contra-Indications (Apically positioned flap
without osseous surgery)
Anatomical reasons:due to location of the
pocket.(e.g.. Anterior oblique ridge in the
mandible in the 3rd molar area.
 Esthetic and cosmetic reasons: Anterior
area with high lip line.
 Severely compromised Alveolar bone
Apically positioned flap with
osseous surgery
We remove bone to have normal
architecture by doing Osteoplasty or
 Indications:
 Pre-restorative periodontal
procedures(exposure of crown).
 Active pockets with mild or moderate
infrabony defects where the base of the
pocket is apical to crest of the bone.
Contraindications(Apically positioned flap
with osseous surgery)
 Anatomical
crown\root ratio.
 Presence of excessive tooth
 Osteoctomy:
 Removal of some
alveolar bone, thus
changing the position
of crestal bone on
tooth surface.
 Osteoplasty
 Reshape the bone by
thinning it and not to
reduce from its height
therefore gingiva can
adapt nicely.
Root Resection Therapy
 In
cases of multirooted teeth with
infrabony deep pockets and root
 In case of furcation grade III.
 The bone around the area will be
thin, therefore affected root can be
Objectives of Resective
Pocket elimination or reduction.
 A physiological gingival contour,tightly
adapted to alveolar bone and apical to pre
surgical site.
 A clinically maintainable condition.
Requirements for Resective
Access proper root instrumentation.
Access for underlying alveolar crest.
Maintain adequate band of attached gingiva.
Heal in rapid fashion.
Minimize the alveolar crest height.
Maintain levels of clinical attachment on a long
term basis.
Reduce probing on a long term basis.
New Attachment
Closed curettage.
Excisional new attachment
procedure (ENAP).
Open flap curettage.
Modified widman flap procedure.
Closed curettage
Not common
 The idea is to to remove the epithelium
that lines the pocket wall.
 This will promote natural healing process
 Scientific evidence to prove this is week.
Excisional new attachment
procedure (ENAP).
Done extensively in 1960-----1970---.
Not common now days.
Indicated in localized, mild to moderate
Periodontitis, especially interdentally in the
anterior region.To eliminate suprabony
Advantage is minimum tissue loss.
Disadvantage, is limited vision and it is not
applicable in case of deep or irregular pockets
Modified widman flap procedure
&Open flap curettage
Most common done periodontal surgery.
 Internal bevel incision.
 Reflect flap,clean the area.
 Position the flap back to its original site,
therefore have attachment between tissue
and root surface.
 Pocket is reduced.
Grafts, bone grafts, soft tissue grafts.
 Guided tissue regeneration.
 Coronal positioned flap.
 Root surface demineralization (citric
acid chemicals).
 Interdental denudation.
Not predictable nor overwhelming.
 Auto grafts (from same person, two step
procedures,freeze and dry the bone.
 Allografts (from same species).
 Alloplasts (from synthesized materials),an
implant from inert material.
Guided tissue regeneration
To guide the right type of cells
(periodontal ligament)to attach to root
surface, and trying to exclude undesirable
cells(epithelium) from attaching to root
Root surface demineralization
Modify the root surface that the right type
of cells will attach to it.
Factors influencing the success or failure
of all regeneration techniques
Plaque control.
Systemic status that affect the periodontium.
Traumatic injury to teeth and tissue.
Root preparation.
Wound closure.
Soft tissue approximation.
Post operative and long term maintenance.
Criteria for method selection
Characteristics of the pocket: depth,relation
to bone,and configuration.
Accessibility to instrumentation, including
presence of furcation involvements.
Existence of mucogingival problems.
Response to initial therapy.
Plaque control.
General health.
Diagnosis of the case and previous
periodontal treatment.
Aesthetic consideration.
Post operative instruction
Pain killer
Keep pack in place.
Avoid hot food.
Use ice pack on the face.
Do not brush the area.
Use mouth rinse after one day.
Do not smoke, follow normal activity, however
avoid excessive exertion.
Come back to your next appointment.
Surgical versus non surgical treatment of
periodontal disease is controversy.
 Only moderate and sever pockets should
be treated surgically.
 Doing surgery in shallow pocket will result
in attachment loss.
 Gain in attachment will be more after
surgery than non-surgery in deep pocket.
Thank you